Examination of witnesses (Questions 80
THURSDAY 15 MARCH 2001
and DR BRIAN
80. One of the issues that arose there was the
way in which resourcing which was primarily for local authority
services went in sometimes through National Health Services. Is
that something you feel might be helpful? Where we have this problem
of working across boundaries do you feel there might be more scope
for you as Chief Executive of a trust to influence the process
of rehabilitation bearing in mind the point made by you about
(Mr Pope) I think in my area there has been a great
deal of flexibility between health and social care.
81. There has been?
(Mr Pope) There has been I think. What we should be
focusing on is the outcome, what we are trying to achieve. It
does not matter whether it fits into those boxes. I think that
is something I have seen particularly this winter where resources
have been used between the two areas, bearing in mind the constraints
put upon them perhaps within their legal frameworks. There has
been a lot more flexibility and I think there is more to come
with care trusts etc.
82. Could I ask Dr Moffit how much of the brain
injury services are in the private sector?
(Dr Moffit) There is quite a high level of provision
in the private or independent sector. It has been mentioned already
that there is an enormous range of need amongst people with brain
injuries. There is a very large population of people with brain
injury who get services almost exclusively from the National Health
Service and a very small number who get a service from the private
sector. Perhaps you are hinting at the fact that consumes a lot
of resource because of the severity of the problem affecting those
individuals but in terms of percentage the vast majority of treatments
for people with brain injury is within the National Health Service.
83. Are you able in a very broad way to put
a percentage figure on what "vast majority" means? Are
you talking about 90 per cent, 95 per cent?
(Dr Moffit) I would have thought it was 99 per cent.
I would have thought it was as high as that. The percentage in
the independent sector was incredibly low, or perhaps the percentage
of services that should be delivered.
(Dr Andrews) I think it depends what level of service
you are looking at. I think most of the original early treatment
of brain injury is on the NHS. If you look at the very specialist
services for brain injury, the vast majority is in the independent,
either the private or the charitable sector, once you get down
to the super specialist type of care.
84. In the private sector who is paying for
(Dr Andrews) Most of that comes from contracts with
85. Could I ask a follow up. Dr Andrews was
nodding his head very vigorously when I asked about OATs and ECRs.
Is this something that you would like the Government to address,
the funding stream?
(Dr Andrews) I think one of the problemsand
this is something again which I must say the London Specialist
Commissioning Group is very concerned aboutis the lack
of flexibility almost across districts. I think one of the strengths
that you can put forward to the Government is that they really
need, first of all, for health authorities to have information
about how many brain injured people they have got, which they
do not generally have, and the levels of disability. They need
to have care pathways drawn up and that will include moving out
of your own health authority to the most appropriate within your
area. In fact, we are all keen that there should be very clear
information about what is available, what the waiting times are
and how you get into those and really for there to be preferred
units to go to from the health authorities. That way you need
to move money across districts to be able to enable people to
get the best treatment. This is why again I think the specialist
commissioning at a region or a multi PCT level is going to be
required. That is what OATs is actually doing.
86. You see the answer being specialist commissioning
rather than back to the ECR type arrangement? It was interesting
listening to the earlier witnesses where clearly a health authority
cannot anticipate (a) how many injuries they will have and (b)
cannot always work out whether it is better for those people to
be near relatives which may be nowhere near the home district.
(Dr Andrews) Yes.
87. It may well be it is in the interests of
the patient to be outside the pattern that you are describing.
Certainly I am having difficulty with my own patients to achieve
(Dr Andrews) Yes.
Chairman: On this point about specialist commissioning,
obviously we have wrestled with these areas in a number of other
specialist areas as well, particularly mental health. Do you have
any thoughts on how that structure might be achieved? Are we talking
here about some of these specialist units in areas? Are we talking
about some common new body that may be called a PCT that would
handle this kind of commissioning?
Dr Brand: Regional Health Authorities.
(Dr Andrews) I suspect it is going to be dealt with
differently in different areas. If you have a very intensive area,
such as London, then it is easy to work across districts. If you
are in a more rural area it is very much more difficult to get
that level of collaboration. This means that you then are having
to travel long distances to get the level of care that you require.
I would assume in some areas that it should be the old Regional
Health Authority type of commissioning that a group of that size
takes it on or a group of health authorities or even a group of
PCTs. Personally I do not care who does it as long as it is done
effectively and at the end of the day the patient gets the best
treatment in the most appropriate place.
89. Could I ask Dr Turner-Stokes and Mr Pope
how have you managed to develop a good service for brain injured
people in your area given that obviously from the evidence we
have had others have not been able to do that? Obviously your
own enthusiasm is important but were there other special factors
that enabled you to do that? What is stopping other trusts and
health authorities from doing the same thing?
(Dr Turner-Stokes) First of all, I would say we are
not perfect and we have still got gaps, but we have gone some
way down the route. I think there are three main factors that
help. Firstly, there was a sum of funding and that came from the
dissolution of ALAC, which was the wheelchair and prosthetic service.
Central funding for that was devolved down and in our region due
to the foresight of North West Thames Health Authority and the
efforts of my colleague, Andrew Frank, that was put together to
make a regional service. Secondly, we were specifically instructed
in that service not just to be a unit that was self-sufficient
and did not talk to anybody else but to be a catalyst for development
of services across the region. That was our brief. So the organisation
was of the hub and spoke model which I have presented evidence
on and also expanded on quite a bit. The idea was not only to
be a centre of clinical excellence but also a centre for training
and research across the region. That has meant we trained professionals
from all disciplines involved in rehabilitation training programmes,
so that very often when services are being set up now around the
region those are populated by people we have trained. That comes
back to it is not just about resourcing but the training and keeping
that going. Thirdly there is the enthusiasm. I think I would have
to say that there has been tremendous collaboration from all the
consultants around us in the region and in the teams, especially
my own, who really have worked all hours God gives. That is the
crucial thing. It takes a huge amount of effort. One of the things
that one cannot really quite emphasise enough is that you need
to know that you have got continuity of funding. You need to know
it is long term so you can put in the infrastructure that was
identified. It takes ten years to develop a team and you have
got to know it is not going to be disbanded next month or next
year because the contracts are going to change, or we might not
get ECRs, or we might have to lose some people. I think that is
critical, so specialised commissioning will give the stable funding.
Finally there is the support of the Chief Executive. Then it was
Mike Cole, John's predecessor, but hopefully now John and his
team will be giving support to develop it. Those are the crucial
things allowing us to develop the service. I can talk about some
of the barriers but I have talked enough.
(Mr Pope) I do not think there is much to add in some
ways. It is back to the issue about when does it become a priority,
and sometimes it takes a team that has a vision as to how things
can be. The way that works with chief executives is if you have
something that is comprehensive, if I had one clinician coming
at me, perhaps just a doctor, I would be looking for the therapists,
I would be looking for the links to other hospitals, I would be
looking for work with primary care and perhaps the voluntary sector.
That would make it attractive to me and I am sure that is a bit
of how this service came together. Sometimes the inspiration is
not there and you need help from groups like this to push something
and say this is how it can be. The barriers are clear. There are
many, many competing priorities as we are going through a massive
amount of change in the service.
90. I am curious about joint commissioning.
Leaving aside the complexities of PFI, there will be some capital
as well as revenue expenditure on the services. Do they come down
a different route and is that a problem for the joint commissioning
(Dr Andrews) I do not think I am quite with you on
the concept here.
91. The sources of the revenue are different.
Does that make a problem in planning comprehensively?
(Dr Andrews) At the end of the day most things in
health care or in any organisation depend on people and if you
can get the relationships between two organisations rightand
we all know of health and social service departments who have
the same office and others who will not speak to each other. That
all boils down to people. What is really required is very clear
guidelines on who takes responsibility for which element of funding.
You can look at a nursing home now and find that one patient is
being funded entirely by the health authority, another one with
exactly the same problems joint funded, and a third one is being
funded purely by social services with all the implications of
means testing. There is something wrong if we cannot get very
clear guidelines so we can have equity across the country. That
is what is required, guidelines of who should take responsibility,
at what level and a mechanism whereby people are forced to discuss
things. One of the strengths of the PCTs will be this greater
relationship with social services as part of that primary care
(Dr Moffit) There is no doubt that there are some
niche services already provided in the independent sector. If
specialist commissioning continues to provide funding for patients
in the same way as it does at present, and does it more efficiently
so that patients arrive in this sector at an earlier stage then
the value returned to the funders will be greater because if what
you will have delivered is in a more appropriate time and more
effective and lasts for a shorter period, the individual can be
got back to their home area in a shorter period, to everyone's
92. I was going to ask whether the concordat
with the private sector has made any difference in this particular
(Dr Moffit) Not evidently, I have to say. The sentiment
of it really supports the practice in a sense because the patients
who come to the independent sector at the present time are frequently
patients whose needs are so overwhelming that they are funded
because a service has to be found and there is not another available
choice. The concordat does not add to that but, as I understand
it, the philosophy of the concordat would be entirely behind it.
Chairman: Can I thank you for your very helpful
evidence this morning. We are most grateful for the help you have
given this inquiry. Thank you very much.